12.Ante partum Hemorrhage_APH_

							                    Ante Partum Hemorrhage(APH)
Definition: Antepartum hemorrhage is described as bleeding from genital tract in pregnancy after 24
weeks& before the onset of labor.

Incidence: 3% of all pregnancies

The causes of APH can be divided into 3 main groups:

Placenta Abruption (5%)

Placenta Previa (0.4 – 0.8%)

Others; uterine rupture,cervical ectropion, vaginal infection, vulval varices, Heavy show, Marginal

placental bleeding. Genital tract tumors

History: Amount of blood loss, abdominal pain, Provoking factor, Previous LSCS, Myomectomy.
History of D&E

Examination:




  VITALS                  B.P., Pulse, Temperature, R.R




  P/A                     H.O.F., Abdominal Tenderness, Lie, Presenting Part, Fetal Hearts, (woody
                          hard)




  P/V Examination         Contraindicated unless placenta previa excluded




Investigations:

       CBC
       PT/APTT/INR
       Electrolytes/LFTS
       Renal Function Tests
     Blood group and Rh Factor
     CTG
     U/S Pelvis for F.W.B. and Placental localization




Management:

     Call for help, senior staff, the consultant, the pediatrician, the hematologist, anaesthetist
     Inform the O.T.
     ABC, if patient is in shock
     Access----- Airway
     Maintain -----100 % O2
     Breathing

     Circulation

     15 degree tilt
          o   Important to realize that the blood loss is usually underestimated

     2 large borei.v cannulae 14G
     Cross match 4-6 unit of packed cells and FFP
     Initially administer upto 2 liters normal saline followed by colloids
PLACENTA PRAEVIA                                   PLACENTAL ABRUPTION



PLACENTA PREVIA                                    PLACENTA ABRUPTION

Mild bleeding: (< 200ml)                           Mild to Moderate bleeding:

-Wait and watch & keep under observation.          -Transfuse blood.

Moderate bleeding: (200- 1000ml)                           If Fetal distress:

-Transfuse blood and monitor vigilantly.           -Delivery imminent: Vaginal delivery

-EL LSCS at 38 wks for Previa only.                -Delivery not imminent: Lscs

-EL LSCS at 36-37 wks for suspected                If No fetal distress or fetus is dead:
Placenta Accreta.
                                                   -Cervix favorable :deliver vaginally
                                              rd
-Placental edge < 2cm from internal os in 3
                                                   -Cervix not favorable:
trimester is likely to deliver by LSCS

                                                    Induce/Augment accordingly, if no progress in 2-4
Massive bleeding: > 1000ml
                                                   hrs/fetal distress/heavy bleeding :LSCS
-Systolic B.P <100mmHg, pulse >120/min,
                                                                                rd
                                                   -Active management of 3 stage of labour
altered consciousness

                                                   Massive bleeding: >1000ml
-Manage shock.

                                                   Manage shock.
-Deliver by LSCS irrespective of gestation.
                                                   Transfuse Blood, FFPs & Cryoprecipitate
-Prior to delivery patient & partner should be
counselled about all risks including               Fully dilated & imminent delivery: Deliver vaginally.
hysterectomy.                                      Delivery not imminent & FHS present: LSCS
                                                   Counsel about NICU care and outcome of baby
-Anesthesia choice would be decided by
                                                   according to gestational age.
anesthetist.

-Consent form should include :

Blood transfusion,
Hysterectomy.
Admission in ICU

-Anterior placenta overlying previous scar
manage as accreta.

-Insert 800microgram misoprostol per rectally
after caesarean section to prevent PPH
PLACENTA PRAEVIA                                   PLACENTAL ABRUPTION



PLACENTA PREVIA                                    PLACENTA ABRUPTION

Mild bleeding: (< 200ml)                           Mild to Moderate bleeding:

-Wait and watch & keep under observation.          -Transfuse blood.

Moderate bleeding: (200- 1000ml)                           If Fetal distress:

-Transfuse blood and monitor vigilantly.           -Delivery imminent: Vaginal delivery

-EL LSCS at 38 wks for Previa only.                -Delivery not imminent: Lscs

-EL LSCS at 36-37 wks for suspected                If No fetal distress or fetus is dead:
Placenta Accreta.
                                                   -Cervix favorable :deliver vaginally
                                              rd
-Placental edge < 2cm from internal os in 3
                                                   -Cervix not favorable:
trimester is likely to deliver by LSCS

                                                    Induce/Augment accordingly, if no progress in 2-4
Massive bleeding: > 1000ml
                                                   hrs/fetal distress/heavy bleeding :LSCS
-Systolic B.P <100mmHg, pulse >120/min,
                                                                                rd
                                                   -Active management of 3 stage of labour
altered consciousness

                                                   Massive bleeding: >1000ml
-Manage shock.

                                                   Manage shock.
-Deliver by LSCS irrespective of gestation.
                                                   Transfuse Blood, FFPs & Cryoprecipitate
-Prior to delivery patient & partner should be
counselled about all risks including               Fully dilated & imminent delivery: Deliver vaginally.
hysterectomy.                                      Delivery not imminent & FHS present: LSCS
                                                   Counsel about NICU care and outcome of baby
-Anesthesia choice would be decided by
                                                   according to gestational age.
anesthetist.

-Consent form should include :

Blood transfusion,
Hysterectomy.
Admission in ICU

-Anterior placenta overlying previous scar
manage as accreta.

-Insert 800microgram misoprostol per rectally
after caesarean section to prevent PPH
References

1 .Royal College of Obstetrics and Gynecologists. Antepartum Hemorrhage Green-top Guideline No. 63
1st edition November 2011


2 .Royal College of Obstetricians and Gynaecologists. Placenta Praevia, Placenta Praevia Accreta and
Vasa Praevia:Diagnosis and Management Green-top Guideline No. 27.London: RCOG; 2011.


3 .Royal College of Obstetricians and Gynaecologists. The Use of Anti-D Immunoglobulin for Rhesus D
Prophylaxis. Green-top Guideline No. 22. London: RCOG; 2011.


4 .Royal College of Obstetrics and Gynecologists. Antepartum Hemorrhage Green-top Guideline No. 63
1st edition November 2011


5 .Royal College of Obstetricians and Gynaecologists. Placenta Praevia, Placenta Praevia Accreta and
Vasa Praevia:Diagnosis and Management Green-top Guideline No. 27.London: RCOG; 2011.


6 .Royal College of Obstetricians and Gynaecologists. The Use of Anti-D Immunoglobulin for Rhesus D
Prophylaxis. Green-top Guideline No. 22. London: RCOG; 2011.